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Reviews Book

The Swine Flu Affair: Decision-Making on a Slippery Disease

BMJ 2005; 331 doi: (Published 24 November 2005) Cite this as: BMJ 2005;331:1276
  1. M G Jacoby, assistant professor of family practice (mgjacoby{at}
  1. Stony Brook University, New York

    In January 1976 an outbreak of upper respiratory disease occurred at Fort Dix, a military base in New Jersey. The state's chief epidemiologist made a bet with the medical officer in charge at Fort Dix that it was in the midst of a flu epidemic. To settle the wager the medical officer sent cultures to the state laboratory. He lost. The cultures showed an unidentified flu virus, which was sent to the Centers for Disease Control and Prevention (CDC) in Atlanta and turned out to be swine flu.

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    Richard E Neustadt, Harvey V Fineberg

    University Press of the Pacific, $27.50, pp 204

    ISBN 1 4102 2202 0

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    At that time any antigenic shift, as was shown in this case, was believed to be the possible forerunner of a pandemic. The then director of CDC, David Sencer, prepared a memorandum for David Mathews, secretary of health, education, and welfare at the time. The memorandum offered four options of a common sort in government: three framed to be rejected by the reader and a fourth one desired by the writer.

    The first was “do nothing,” the second was “minimal response,” the third was a “government program,” and the fourth was a “combined approach,” which added a role for the private sector. This memorandum of action was deliberately designed to force a favourable response from a beset administration, which could not afford to turn it down and then have it leak. The memorandum was presented at a meeting with Mathews on 15 March, where Sencer pressed Mathews hard. Mathews felt that even had the risk seemed far away, it was politically impossible to say no. Although the risks were slight, Sencer pushed the strong possibility of a pandemic related antigenically to the 1918 flu. A decision had to be made within two weeks to give time for the preparation, testing, and administration of the vaccine before the next flu season.

    Theodore Cooper, assistant secretary of health, education, and welfare, was impressed and made Sencer's cause his own.

    On 22 March a meeting was held by President Ford, attended by Mathews and Cooper, and other members of the administration. The president was not warned about six things: trouble with serious side effects, with children's dosages, with liability insurance, with expert opinion, with the public health service's public relations, and with his own credibility. The vaccine was presumed to be safe and efficacious.

    On 24 March at 3 30 pm another meeting was held in the cabinet room with outside scientists, including the inveterate opponents Jonas Salk and Albert Sabin. Summoned to the White House at short notice and overawed, most of those present took it to be “programmed” and “a stage set” and that the decisions had been taken. They felt that “We were used.” A show of hands showed unanimous approval for the programme. Ford asked for any dissent, but there was none. The president then said he would suspend the meeting and go to the Oval Office, where anyone who had doubts could talk to him privately. Nobody did. The president went back to the cabinet room, collared both Salk and Sabin, and went to the press room, where he announced the $135m (£79m; €115m) programme of swine flu vaccination to inoculate every man, woman, and child in the country.

    The rest of the story is well known—the problems of manufacture, the refusal of the insurance companies to issue liability policies, the public's only moderate response to the vaccination programme, the occurrence of Guillain-Barré syndrome and, most noticeable of all, the non-occurrence of an outbreak of swine flu. The whole affair, so well described in this book, is a good example of the fallibility of expert opinion and the fallibility of government.

    The Swine Flu Affair, by members of the Harvard Schools of Government and Public Health, was commissioned by the health, education, and welfare secretary Joseph Califano and first published in 1978. Nevertheless it is racily written and holds the reader's attention as well as any good detective or science fiction novel. It should be required reading for doctors and politicians, as the US government faces the same problems today as it did nearly 30 years ago.